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peech
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athology
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ustralia
INTERVENTION: WHY DOES IT WORK AND HOW DO WE KNOW?
Best evidence
Unlucky Amiel lived in an age of scepticism. By contrast, we
exist in a professional milieu that welcomes accountability,
best evidence and exemplary care. In embracing the “three
Es” of quality assurance – effectiveness, efficiency and effects
(Olswang, 1998) – we understand that “it works for me”, or “I
don’t know why it works but it does” approaches to justifying
why we implement particular interventions simply won’t
wash! Why? Because “professionals should be wary about
trusting their own clinical experience as the sole basis for
determining the validity of a treatment claim” (Finn, Bothe &
Bramlett, 2005, p. 182).
The onus for adopting EBP rests with individual clinicians.
It cannot be imposed by professional associations, employers,
legislators or policy-makers. It is up to us to constantly gather
and objectively view clinical data, reflect, and ask hard questions
about our interventions. Are they theoretically sound? Are
they supported by evidence? Are they effective and valid? Do
they work? Are they efficient? Do they work as well as, or
better than other therapies? Can their efficiency be improved?
And their effects: what changes do our therapies evoke?
Bernstein Ratner (2006) explains why she believes that EBP
is a valuable construct, but cautions that along with those
reflections and hard questions come potentially difficult
issues. These require us establish robust communication at all
points, from laboratory and clinic– that is, between the
funding bodies and researchers who develop the evidence,
the academics who spread the word, the administrators who
regulate change, the employers charged with maintaining
conducive workplaces, the practitioners who implement the
evidence, and the client, who, in egalitarian practice, may
have the last say.
“EBP is a valuable construct in ensuring quality of care.
However, bridging between research evidence and
clinical
practice
may require us to confront potentially
difficult issues and establish thoughtful dialogue about
best practices
in fostering EBP itself (Bernstein Ratner,
2006, p. 257).”
Plane figures
A triangle has three sides and three angles, but it is a plane,
and a plane has no depth. The points on a plane have no
parts, no width, no length and no breadth. But each point has
an indivisible location. Do we accept that EBP is all about
truth and values and that it is located at the junctures between
clinical SLPs’ engagement with scientific theory and research,
their clinical expertise and their respectful engagement with
their clients and their worlds? Or is it deeper and more
complex than that, and is adopting EBP
all
about clinicians
and their responsibilities?
Bridges
Bridges have three necessary parts: substructure, super
structure and deck. The substructure is the foundation of a
bridge comprising the piers and abutments that carry the
superimposed load of the superstructure to the underlying
H
enri-Frédéric Amiel was the name and
pathography
1
was
his game. Not much is heard about the issue of path
ographesis, or the writing out of illness, but it is clear from
Amiel’s
opus magnum
that writing “out” illness was a
complex, melancholy business – part poison, part antidote
and part therapy – that makes writing “about” it seem very
straightforward.
Scarcely acknowledged in his lifetime, international fame
and acclaim came posthumously to this Swiss philosopher
and diarist who lived from 1821 to 1881, when his
Journal
intime
was published and translated into English. He was
outwardly successful as professor of aesthetics, and then as
professor of moral philosophy in Geneva, but because his
were political appointments he struggled with isolation from
the city’s rich cultural life. Left with his own ideas in pursuing
a lonely quest for truth and values through scrupulous self-
observation, his writing both defined and created his ills
(Rousseau & Warman, 2002), never exorcising his demons.
Sad to say, this introspective man, intent upon knowing
himself, thought of himself as a failure: deficient personally
and professionally. Nonetheless, a century and a quarter after
his genius was revealed, the oft-quoted Amiel’s reflections on
the urge to intervene and the need to analyse our motives for,
and methods of, doing so resonate in helpful ways with
contemporary thought on evidence-based clinical practice.
Truth and values
The processes and responsibilities of clinicians who adopt
evidence-based practice are commonly represented diagram
matically as points on an equilateral triangle (ASHA, 2004) in
the
Euclidian plane geometry
2
tradition. Echoing Amiel, two
points of the triangle represent our constant quest for truth:
theoretically, empirically and in practice, and the other point,
our regard for our clients’ values.
W
ebwords
31
Evidence based speech-language pathology intervention
Caroline Bowen
Current best evidence
Clinical expertise
Client/patient values
EBP
At the topmost tip of the triangle is the
clinician’s
dynamic
engagement with science via refereed and non-juried articles,
chapters, proceedings, books and continuing professional
development activity. On the left-hand point is the
clinician’s
expertise: that blend of knowledge, skill and experience, and the
capacity for constructive professional engagement with clients
and their worlds. On the right is the
clinician’s
respect for clients’
beliefs, values, responsibilities and priorities, and an appreciation
of the
assets
(Kretzmann & McKnight, 1993) that the people
we serve bring to therapeutic encounters. In the middle of the
plane is the now-familiar abbreviation, EBP representing the
clinician’s conduct. Yes, this little triangle is
all
about clinicians.